Harrogate BOROUGH COUNCIL

OFFICE USE ONLY HOUSING Date received: Acknowledged: Date logged: APPLICATION Inputting Officer: Application No:

Please use block capitals when completing this form and provide as much information as possible as this will help us to assess your points accurately. You will need to complete every question that applies to you otherwise your application may be rejected. Please note that before you start your application you will need your National Insurance number, your address history for the last five years and, if applicable, your landlord's contact details for your current and previous addresses. Further details on our housing allocation scheme can be found on our website at www.harrogate.gov.uk. If you need any advice or help to complete this form please contact Customer Services on 01423 500600. Personal details

Q1 Main applicant Q2 Joint applicant

Mr/Mrs/Miss/Ms (please delete) Mr/Mrs/Miss/Ms (please delete)

Last name Last name

First name(s) First name(s)

Date of birth Date of birth / / / / Your current address or a contact address Please tell us your relationship to the main applicant, for example, spouse, partner.

Your current address or a contact address

Postcode Your contact telephone number

Postcode Email address Your contact telephone number

National Insurance number Email address

Gender: Male/Female/Other (please delete) National Insurance number

Next of kin Gender: Male/Female/Other (please delete) Name

Telephone Next of kin Name

Telephone We want to shape our housing service to meet the needs of our customers and to make sure that everyone is treated fairly and able to access the service as easily as possible. Questions 3 to 9 are not compulsory but the information Q5 Please enter your religion: you provide will help us to do this. Main Joint Q3 Details of your relationship status applicant applicant (please tick): Buddhist Main Joint applicant applicant Christian Hindu Single Jewish Married/Civil Partnership Sikh Partner Muslim Separated Other Divorced No religion Co-habitee Prefer not to say Widow Widower Q6 Which of the following best Do not wish to declare describes how you think of Q4 Your ethnicity (please tick): yourself? Main Joint Main Joint applicant applicant applicant applicant

Asian or Asian British Bangladeshi Bisexual Asian or Asian British Indian Gay man Asian or Asian British Pakistani Heterosexual/straight Asian or Asian British other Gay woman/lesbian Asian Other Bangladeshi Prefer not to say Black or Black British African Black or Black British Caribbean Q7 Is English your first language? Black or Black British other Main applicant Yes No Black African Black Caribbean If no, please tell us what your first language is. Black other Chinese Joint applicant Yes No Gypsy Roman Traveller

Indian If no, please tell us what your first language is. Mixed other Mixed White Asian Mixed White and Black Caribbean Mixed White and Black African Q8 Do you need this information Pakistani translated into another language? White Yes No White British If yes, what language do you want this White other translating into? Other Do not wish to declare Household personal details (other adults) Q9 Does anyone in the household have a Q10 Please give details of everyone disability under the Equality Act? who needs housing with you. Yes No Mr/Mrs/Miss/Ms (please delete) The definition of a disability according to the Equality Act 2010 is: “A physical or mental impairment which has Last name a substantial and long-term adverse effect on his or her ability to carry out normal day to day activities”. Long-term means more than 12 months. The definition covers long- First name(s) term illnesses such as cancer and HIV or mental health; it includes any adult or child living permanently in the household. Date of birth

If you answered 'yes' to the previous question please National Insurance number answer the further questions about disability below. If you would prefer not to answer these questions, please leave them blank. However, if you are happy to answer them please put a tick against each one that applies. Gender: Male/Female/Other (please delete)

Physical disability Relationship to you for example mother, son. Visual impairment Speech impairment Mr/Mrs/Miss/Ms (please delete) Hearing impairment Mental health problems Last name Long term illness First name(s) Difficulties reading or writing Learning disability Date of birth Disability not listed above Please give details here National Insurance number

Gender: Male/Female/Other (please delete) Relationship to you for example mother, son.

If you need to list more adults who need housing with you, please use the space provided in the 'Additional Information' section Prefer not to say on the back page. Household personal details Main applicant (children) addresses

Q11 Please give details of children who Q12 Starting with your current address, need housing with you. please tell us where you have lived over the last five years and who owned the Last name property, for example private landlord, council, housing association, parents. If you First name(s) are currently of no fixed abode, you must provide a correspondence address. Date of birth Property One Address Gender: Male/Female/Other (please delete) Relationship to you for example son, daughter. Date from / / Date to / /

What is the landlord’s name and address? Do you receive child benefit for them? Yes No

Last name Landlord's contact number/email

First name(s) If not renting, what are your circumstances, for example lodging, owner-occupation. Date of birth

Gender: Male/Female/Other (please delete) Relationship to you for example son, daughter.

Property Two Address Do you receive child benefit for them? Yes No

Date from / / Date to / / Last name What was the landlord’s name and address? First name(s)

Date of birth Landlord's contact number/email

Gender: Male/Female/Other (please delete) If not rented, what were your circumstances, for Relationship to you for example son, daughter. example lodging, owner-occupation.

Do you receive child benefit for them? Yes No Why did you leave?

If you need to list more children who need housing with you, please use the space provided in the 'Additional Information' section on the back page. Q13 If you are liable for rent in your current property, are you in rent arrears? Yes No Property Three If Yes, please provide details. Address

Date from / / Date to / /

What was the landlord’s name and address?

Landlord's contact number/email Q14 If you are currently of no fixed abode, or lodging with family/friends on If not rented, what were your circumstances, for example lodging, owner-occupation. a temporary basis, please provide details of any rent arrears you accrued at your last settled address. Why did you leave?

Property Four Address

Date from / / Date to / / Q15 Have you or anyone included in this application ever had a tenancy in a What was the landlord’s name and address? Harrogate Borough Council property that is not your current property or a property already mentioned?

Landlord's contact number/email Yes No If yes, please provide details

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave?

If you need to list more properties, please use the space provided in the 'Additional Information' section on the back page. Property Three Joint applicant Address addresses Date from / / Date to / /

Please provide this information if the address What was the landlord’s name and address? history differs from that of the main applicant.

Q16 Starting with your current address, please tell us where you have lived over Landlord's contact number/email the last five years and who owned the property, for example private landlord, council, housing association, parents. If you If not rented, what were your circumstances, for are currently of no fixed abode, you must example lodging, owner-occupation. provide a correspondence address. Why did you leave? Property One Address

Property Four Date from / / Date to / / Address

What is the landlord’s name and address? Date from / / Date to / /

What was the landlord’s name and address? Landlord's contact number/email

If not renting, what are your circumstances, for example Landlord's contact number/email lodging, owner-occupation.

If not rented, what were your circumstances, for example lodging, owner-occupation.

Why did you leave? Property Two Address If you need to list more properties, please use the space provided in the Additional Information Date from / / Date to / / section on the back page. What was the landlord’s name and address? Q17 If you are liable for rent in your current property, are you in rent arrears?

Landlord's contact number/email Yes No If Yes, please provide details

If not rented, what were your circumstances, for example lodging, owner-occupation.

Q18 If you are currently of no fixed Why did you leave? abode, or lodging with family/friends on a temporary basis, please provide details of any rent arrears you accrued at your last settled address. Q21 What is your local connection to Your current the district? circumstances Our local connection criteria is explained on our website www.harrogate.gov.uk/localconnection in the housing allocation scheme summary information booklet. Q19 If you or any of the people moving In addition to your five year address history with you are not UK citizens, please detailed in questions 12 and 16, please provide provide details and confirm which any additional local connection details (for country they are a citizen of. example name, address, relevant dates of residency/employment).

Previous resident - this applies if you have previously lived in the district for a continuous period of ten years.

Family who live in the area (please give full details of Q20 In the past five years, if you or their names, addresses, relationship to you and how anyone moving with you have come long they have lived in the Harrogate district). to live in the UK or returned to the UK from living abroad, please provide their name, the country they entered the UK from, and the date they entered the UK.

Your current employment details. Q22 Are you a current or former member Q29 Do you have any pets? of the Reserves/Armed Forces serving Yes No at any time in the five years preceding your application for housing? If yes, please give details. Please give details of length of service and service personnel number. Q30 Medical factors Please give details of yourself and anyone wishing to be housed with you who is suffering from a serious illness or disability that is affected by your Q23 Are you a bereaved spouse or civil accommodation. partner who can no longer live in First Person Ministry of Defence accommodation following the death in service of Last name your spouse or partner? First name(s) Please give details

Name and address of doctor

Q24 Are you a social housing tenant Name of occupational therapist (if applicable). living in England, needing to move into the district to take up an offer of employment? Please provide details Details of illness / disability and reasons why your current accommodation is no longer suitable.

Q25 Does any member of the household own a property anywhere in the world? Second person Yes No Last name

First name(s) Q26 Is the combined household income more than £60,000 per year? Name and address of doctor Yes No

Q27 Are the combined household savings Name of occupational therapist (if applicable). more than £120,000? Yes No

Details of illness / disability and reasons why your Q28 Are you or any of these people to be current accommodation is no longer suitable. rehoused with you expecting a baby? Yes No If yes, please state their name and when the baby is due. If there are any other people with a medical condition, please give details in the 'Additional Information' section on the back page. Q31 Is there anyone who you would like to support your application - such Your current home as a social worker or care assistant, Q33 What type of home do you or a friend or relative who provides live in now?(Please tick) care or support? House Please give their full name, address and contact telephone number. Flat Bungalow

Maisonette

Mobile home size

Bed and breakfast (specify feet or metres)

Bedsit

Shared House

Hostel Do you think you will need additional support if we are able to offer you accommodation, for example Other (please specify) budgeting, or understanding correspondence?

Q34 What floor is your current accommodation on? (Please tick) Ground First Second

Q32 Details of any convictions. Other (please specify) If you or anyone included in this application has ever been convicted of a criminal offence, or been involved in any inappropriate activity, such as anti- social behaviour, please give details. Q35 What type of amenities Name do you have? (Please tick) Yes No Living room Date of offence(s) Separate kitchen

Details Separate bathroom

Inside toilet

Hot water supply

Cold water supply

Q36 Do you share any of these rooms with someone NOT being rehoused with you? (Please tick) Yes No Living room

Dining room

Kitchen

Bathroom

Toilet Q37 How many bedrooms are there in your home? About the home you want (Please tick ‘Single’ or ‘Double’ and whether Please state your reasons for applying. it is for you/your family’s 'Sole Use') Single Double Sole Use Bedroom 1

Bedroom 2

Bedroom 3

Bedroom 4

Q38 Do you have a garden/enclosed yard? Yes No

Q39 Is your home in a poor state of repair? Yes No Q42 What type of home do If ‘yes’ please give details? you require? (Please tick) House Bungalow Maisonette Q40 What is your current accommodation Bedsit - ground floor only type? (Please tick) Bedsit - any floor Secure tenancy Flat - ground floor only Assured Shorthold tenancy Flat - any floor Assured Shorthold tenancy with notice to quit (Section 21 Notice) Q43 Do you require adapted Assured tenancy - housing association accommodation? Hospital and no other accommodation (Please tick) Yes No Lodger Level access shower Owner-occupier Full wet room In prison and due for release Ramped access Living with relative/friends Fully wheelchair accessible Sleeping rough Stair lift Tied accommodation Through floor lift Temporary accommodation Grab rails for bathing or toileting Other Grab rails - other Multiple adaptations Q41 If you have been asked to leave your present accommodation please give details. Q44 Does any member of your household Please provide written proof. need their own bedroom for medical reasons? What is the date you have to leave by? Yes No Who asked you to leave? If yes, please specify who and why.

Why do you have to leave? Location choices Q45 You are able to choose the location of your preferred accommodation, although YOU MUST CHOOSE A MINIMUM OF FOUR out of the sixteen main lettings areas across the Harrogate district and one of those areas must include either Harrogate, Knaresborough or Ripon. If you don't choose four areas, your application will be rejected. Please indicate the four or more areas you would like to be considered for by ticking the boxes below. Please refer to the map showing the letting areas. It is advisable to widen your choice as much as possible, but for more rural areas please check the availability of facilities such as public transport before making your choices. You will receive a maximum of two offers of accommodation. You may select up to 16 areas. THIS DOESN'T APPLY IF YOU ARE SPECIFICALLY INTERESTED IN SHELTERED HOUSING. PLEASE SEE Q46 FOR MORE INFORMATION ON SHELTERED HOUSING AND THE INDEPENDENT LIVING SERVICE.

1 Harrogate 2 Knaresborough 6 Vale of York 01011 Harewood & Scriven 06102 Marton-cum-Grafton Newby 02010 Briggate 06103 Green Hammerton Bramham Markenfield 02S09 Windsor Lane 06104 Nun Monkton 01012 Lichfield 02030 Stockwell 06110 Hunsingore Norwich 02S13 Stockwell Grove 06113 Kirk Hammerton Lincoln 02040 Inman 06115 Moor Monkton 01013 Harlow/Otley Road (housing association) 02050 Central 06720 Lower Dunsforth 01020 Oakdale 02060 Charlton 06800 Great Ouseburn 01S06 Alder Road 02S14 Charlton Drive 06880 Little Ouseburn 01031 Woodfield 02070 Manor 06960 Whixley 01S07 Woodfield Square 02S12 Manor Court 01032/01S05 Dene Park 02940 Scriven 7 Lower Wharfedale 07121 Follifoot 01033 County 3 Ripon 07122 Little Ribston 01034 Skipton Road 03010 Lead Lane & Spofforth 01035 New Park 03020 Holmefield 07135 North Deighton 01036 High Harrogate/ 07136 Kirk Deighton Devonshire (housing 03S17 Russell Dixon Square association) 03030 Northern 07141 Kirkby Overblow 01041 St Andrews 03040 Central 07149 Sicklinghall 01042 Fairfax Walworth Cawthorn 4 Boroughbridge 8 Upper Wharfedale 08106 Fewston 01S03 Fairfax Avenue 04270 Cundall 08107 Norwood 01S04 Wedderburn Road 04460 Skelton-on-Ure 08131 Askwith 01043 Eleanor & 04470 Kirby Hill 08140 Newall with Clifton Wetherby Road 04630 Roecliffe 01044 Knaresborough Road 04640 Boroughbridge Hospital Site (housing 9 Lower Nidderdale association) 04S24 Springfield, Boroughbridge 0961S Shaw Mills 01045 Forest Moor 0464L Langthorpe 0961T Bishop Thornton (housing association) 0464M Minskip 01050 Starbeck 09820 Nidd 01S01 Station View 09910 Birstwith 5 Knaresborough Villages 09920 Hampsthwaite 01S02 Spa Mews 05101 Goldsborough 09930 Killinghall 01060 Central 05102 Flaxby 01070 Oatlands/Pannal/ 05700 Staveley St Georges/Boulevards (some are housing 05780 Arkendale association) 05830 Scotton

05850 Ferrensby 10 Upper Nidderdale 13 Marston Villages 15 Ripon South Villages 10170 Lofthouse 13001 Tockwith 15001 Markington 1049G Glasshouses 13002 Long Marston & 15002 Bishop Monkton Hutton Wandesley 10S21 Lupton Close, 15003 Burton Leonard Glasshouses 13003 Bilton in Ainsty & 15004 South Stainley 1049P Pateley Bridge Bickerton 13004 Wighill 10S20 Nidd Walk & Southlands, 16 Ripon West Villages Pateley Bridge 14 Northern Villages 16001 North Stainley 10S25 Netherdale, 14001 Baldersby Pateley Bridge 16003 Kirkby Malzeard 14002 Wath 10660 Summerbridge 16S19 Mowbray Crescent & High 14003 Melmerby Street, Kirkby Malzeard 10900 Darley 14004 Hutton Conyers 16004 Winksley 10S22 Valley Road, Darley 14005 Nunwick 16005 Sawley 11 Masham Area 14006 Rainton 16006 Littlethorpe 11030 Masham 14007 Asenby 14008 Dishforth 12 Pannal Villages Please check 14009 Sharow 12001 Beckwithshaw the map below 14010 Copt Hewick 12002 North Rigton for the location 14011 Marton-le-Moor 12003 Weeton & Huby of your chosen 14012 Bridge Hewick 12S23 Kingsway, Weeton area

Map of Harrogate District Showing Letting Areas 1. Harrogate (see stock list for further details) 2. Knaresborough & Scriven 3. Ripon MASHAM 4. Boroughbridge 5. Knaresborough villages 11 6. Vale of York Baldersby St James 7. Lower Wharfedale Wath 8. Upper Wharfedale Kirkby Malzeard Melmerby 9. Lower Nidderdale villages Lofthouse North Stainley 14 Rainton 10. Upper Nidderdale Hutton Conyers 11. Masham area Dishforth 12. Pannal villages Winksley Sharow Copt Hewick 13. Marston villages 16 14. Northern villages 3 Skelton Sawley RIPON 15. Ripon south villages 10 Langthorpe Kirby Hill 16. Ripon west villages

Bishop Monkton 4 BOROUGHBRIDGE Markington Minskip PATELEY BRIDGE Burton Leonard 15 Marton cum Grafton Glasshouses Bishop Thornton Dunsforths Staveley Summerbridge Shaw Mills Great Ouseburn Arkendale Little Ouseburn Darley Birstwith 5 Scotton Hampsthwaite 9 Flaxby Killinghall Whixley6 2 Green Hammerton KNARESBOROUGH 1 Goldsborough Kirk Hammerton HARROGATE Hunsingore Beckwithshaw Little Ribston Tockwith 13 8 7 Long Marston North Rigton Spofforth North Deighton Bickerton Kirk Deighton Bilton in Ainsty Huby12 Askwith Weeton Kirkby Overblow Wighill Ilkley Newall with Clifton Sicklinghall

Otley © Crown copyright and database rights 2015 Ordnance Survey 100019628. Independent Living Service Q46 The council has six sheltered housing schemes of purpose built flats with an emergency call system for people aged 60 or older who are still able to live independently, but who would benefit from the security and the support of an Independent Living Officer. These schemes are Carlton Lodge - Harrogate; Collins Court and Hewitson Court - Knaresborough; Bondgate Court and Blossomgate Court - Ripon and Maple Creek - Masham. Sheltered Housing Schemes

01S08 Carlton Lodge 02S11 Collins Court

02S10 Hewitson Court 11S18 Maple Creek

03S15 Bondgate Court 03S16 Blossomgate Court

Harrogate Lifeline Service We also offer an Independent Living Support service for anyone aged 60 years or older. This is available to anyone - social housing tenants, homeowners or those renting privately. Support is provided by an Independent Living Officer, via a Lifeline unit using the property's telephone land line.

To be considered for either our sheltered housing accommodation or Harrogate Lifeline Service you will be asked to complete a needs assessment to identify your particular needs and the support you require. Although both these types of support are principally for people aged 60 years or older, we also consider other vulnerable people subject to a support needs assessment. If you are interested in Older Persons Independent Living Support Service and you need some additional support, please provide brief details of your needs in the 'Additional Information' section on the back page.

HomeSwapper Mutual Exchange Service If you are an existing social housing tenant we recommend that you register for a home swap at www.homeswapper.co.uk

Connections Q47 Employees of housing providers Q48 Elected member or members of staff Do you, or anyone in your household, or anyone related to you, work for any of the housing providers you have Are you, or any member of your household, related to applied to? any Harrogate Borough Council elected member, or Yes No member of staff? If ‘yes’ please give their name and who they work for: Yes No If ‘yes’ please give their name and relationship to you:

Name of relative

Relationship to you Declaration Q49 Please read this declaration carefully and then sign it. If you are applying jointly, you both need to sign it. To find out what your rights are please go to our website www.harrogate.gov.uk/privacynotice

 I/we consent to the council obtaining/releasing information to other landlords/landlords’ agents/professional housing organisations/government agencies/medical professionals if necessary relating to my/our application.  I/we explicitly consent for North Yorkshire Police to disclose details of my/our previous criminal convictions, any risk assessments they have carried out, or agencies they know to have carried out risk assessments in relation to me/us; also, any information that the police may have relevant to future crime prevention and community safety issues relating to me/us to Harrogate Borough Council for the purpose of permitting them to manage any risk, and reduce potential for future re-offending.  I/we understand that the information contained on my/our application may be released to the Audit Commission in respect of the National Fraud Initiative to detect fraud against the public purse and the council may share this information for the same purposes with other organisations that handle public funds.  I/we understand that if I/we have come to live in this country within the last five years, the council may have to approach the Home Office to check the information I/we have given in this form and to obtain further related information.  I/we understand that legal action may be taken against any person who obtains accommodation as a result of giving false or misleading information or withholding information which has been requested.  I/we will inform the council in writing if my/our circumstances change.

Applicant’s signature Date

Joint Applicant’s signature Date

Please use this space to note any additional details to support your application.

Please return this form to: Housing and Property, Harrogate Borough Council, PO Box 787, Harrogate, HG1 9RW. HBC MAR2018 JS